This case requires us to examine the elements of proof necessary to establish a viable workers' compensation claim for a physical injury induced by job-related stress. Claimant, Darwin Baggett, filed a claim alleging that workplace stress caused him to suffer a heart attack, leading to extensive brain damage. While the arbitrator found in Baggett's favor, the Industrial Commission (Commission) rejected his claim. The circuit court of Williamson County then set aside the Commission's findings. The appellate court vacated the circuit court's order and reinstated the Commission's decision. No. 5-99-0053WC (unpublished order under Supreme Court Rule 23).

We allowed Baggett's petition for leave to appeal to determine whether the Commission erred by requiring Baggett (1) to prove that his injury occurred in the course of and arose out of his employment by showing (a) a greater degree of stress than co-workers, and (b) unusual and increased stress in the workplace at the time of injury; and (2) to prove a strict, scientific causal relationship between stress and the physical cause of injury. We find that the Commission erred. Accordingly, we reverse the judgment of the appellate court and affirm the circuit court's judgment.

I. BACKGROUND

On March 13, 1990, Baggett, a high school industrial arts teacher for the Marion school district (District), collapsed at work. Baggett's collapse was caused by upper gastrointestinal tract bleeding, resulting in reduced blood volume. The reduced blood volume led to a myocardial infarction, cardiac arrest, and resulting anoxic brain damage, rendering Baggett permanently and totally disabled. Baggett then filed a claim under the Workers' Compensation Act (Act) (820 ILCS 305/1 et seq. (West 1998)).

On November 9, 1994, an arbitrator conducted a hearing on Baggett's claim. Fourteen witnesses testified on Baggett's behalf, including his wife, former students, fellow faculty members, and friends in the community. In general, those witnesses testified about Baggett's supervisory duties, other job demands, time deadlines, and the hazardous nature of the construction activities involving young students. Most of the witnesses confirmed that Baggett worked under stressful conditions and stated that they observed the effects of such stress upon Baggett.

A number of witnesses supported the District's contention that all teachers labored under varying degrees of stress. Witnesses also observed that Baggett was not working under any significantly different type of stress than other teachers and that there was no change of stress demonstrated at or near the time of the collapse. The District presented evidence that Baggett was a nervous person in general, that Baggett was involved in substantial nonschool activity contributing to his overall stress levels, and that he may have been more susceptible to mental stress than his co-workers.

Five doctors provided varying medical testimony as to whether stress caused Baggett's injury. Dr. Robert Morgan, Baggett's family physician, testified that Baggett suffered from a stomach disorder likely caused by stress. Dr. Clifford Talbert, Jr., a cardiovascular specialist, attended to Baggett at the hospital after Baggett's collapse. Dr. Talbert explained that Baggett's heart attack was caused by loss of blood resulting from a peptic ulcer. Dr. Wilfred Lee, a gastrointestinal specialist, also examined Baggett after the collapse. Dr. Lee concluded that stress can be a causative factor of the bleeding but that the bleeding could have also been caused by other factors.

Dr. Ralph Graff, a specialist in gastrointestinal diseases and disorders, reviewed Baggett's medical records and the depositions of the other physicians, and indicated that Baggett's condition was more likely a result of an acute ulcer in the upper gastrointestinal area. Dr. Graff pointed out that in contrast to an acute ulcer, a chronic ulcer would leave scars. The records showed no chronic ulcer scars. Thus, Dr. Graff stated that the he needed to know the precise location of the bleeding to find a causal connection between the stress and the bleeding.

Consistent with Dr. Graff's opinions, Dr. Virginia Weaver, a specialist in occupational medicine, testified that she could not find a causal connection between the stress and the bleeding condition. Dr. Weaver testified that the medical records did not conclusively indicate the precise location of the bleeding. Absent medical documentation of the precise location of the bleeding, the bleeding could have been caused by one of several factors. Dr. Weaver also stated that no scientific studies on a population basis showed a causal connection between stress and peptic ulcers.

Upon hearing the preceding evidence, the arbitrator found that Baggett's injuries arose out of, and were suffered in the course of, his employment. Additionally, the arbitrator determined that Baggett was entitled to benefits for permanent total disability and medical expenses.

The District rejected the arbitrator's decision and sought review by the Commission. On April 3, 1997, the Commission reversed the arbitrator's award, finding that Baggett failed to prove either that he sustained an accidental injury arising out of, and in the course of, his employment or that a causal relationship existed between the accident of March 13, 1990, and his medical condition of ill-being. Specifically, the Commission found as follows:

"The commission finds that [Baggett] failed to prove he was subjected to a greater degree of emotional strain than that to which all workers are occasionally subjected. The evidence presented by [Baggett] failed to show that [his] job provided unusual stress in general, and no increased stress around the time of his collapse, on March 13,1990. Therefore, the Commission reverses the [d]ecision of the [a]rbitrator and finds that [Baggett] failed to prove an accident arising out of and in the course of [his] employment on March 13, 1990."

The Commission further found that:

"[Baggett] failed to prove that his present condition of ill-being is causally related to [his] alleged injury on March 13, 1990. The evidence presented by [Baggett] failed to show what the actual source of bleeding which presumably occurred in the upper gastrointestinal tract area was, or any scientific correlation between the stress and the gastrointestinal bleeding. Therefore, the commission reverses the [d]ecision of [a]rbitrator as to causal connection and finds that [Baggett] failed to prove that a causal connection exists between [the] alleged accident on March 13, 1990, and [his] present condition of ill-being."

Additionally, contrary to the express stipulation of the parties, the Commission found that Baggett was not permanently and totally disabled.

On December 13, 1998, upon judicial review, the circuit court set aside the Commission's order and adopted the arbitrator's conclusions, finding that the Commission's decision contradicted the manifest weight of the evidence. Specifically, the circuit court ruled that the Commission imposed improper standards of proof, requiring Baggett to introduce evidence relating to issues of increased and unusual stress, a scientific correlation between stress and gastrointestinal bleeding, and the precise source of bleeding.

The appellate court then reversed the circuit court's judgment and reinstated the Commission's decision. In effect, the appellate court limited its inquiry to whether the medical testimony supported the Commission's determination. The appellate court failed to address whether the Commission used improper standards in reaching its decision. Two justices dissented and filed a statement that this case involves a substantial question warranting consideration by this court. 177 Ill. 2d R. 315(a).

We allowed Baggett's petition for leave to appeal to determine whether the Commission erred by requiring Baggett to (1) prove that his injury occurred in the course of and arose out of his employment by showing (a) a greater degree of stress than that experienced by co-workers, and (b) unusual and increased stress in the workplace at the time of injury; and (2) prove a strict, scientific causal relationship between stress and the physical cause of injury.

II. ANALYSIS

As a threshold matter, the parties disagree as to the proper standard of review. Baggett argues that the Commission used improper legal standards to make its factual determinations, and therefore a de novo standard is appropriate. The District disagrees and argues that the Commission did not consider improper factors. Instead, the District contends that the Commission simply based its decision on Baggett's failure to prove a greater degree of emotional stress than experienced by the general public and a lack of proof of ...

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